Use of N-acetylcysteine plus simethicone to improve mucosal visibility in upper digestive endoscopy via systematic alphanumeric-coded endoscopy: a randomized, double-blind controlled trial.

Background: The use of antifoaming and mucolytic agents prior to upper gastrointestinal (GI) endoscopy and a thorough systematic review are essential to optimize lesion detection. This study evaluated the effect of simethicone and N-acetylcysteine on the adequate mucosal visibility (AMV) of the upper GI tract by an innovative systematic method. Methods: This randomized, double-blind controlled trial included consecutive patients who underwent diagnostic upper GI endoscopy for screening for early neoplasms between August 2019 and December 2019. The upper GI tract was systematically assessed by systematic alphanumeric-coded endoscopy. Patients were divided into 4 groups: 1) water; 2) only simethicone; 3) N-acetylcysteine + simethicone; and 4) only N-acetylcysteine. The following parameters were assessed in each group: age, sex, body mass index, level of adequate mucosal visibility, and side-effects. Results: A total of 4564 images from upper GI areas were obtained for evaluation. The mean AMV in the 4 groups was 93.98±7.36%. The N-acetylcysteine + simethicone group had a higher cleaning percentage compared with the other groups (P=0.001). There was no significant difference among the remaining groups, but several areas had better cleaning when a mucolytic or antifoam alone was used. No side-effects were found in any group. Conclusion: The combination of N-acetylcysteine plus simethicone optimizes the visibility of the mucosa of the upper GI tract, which could potentially increase diagnostic yield.

International consensus on the management of large (≥20 mm) colorectal laterally spreading tumors: World Endoscopy Organization Delphi study.

OBJECTIVES: There have been significant advances in the management of large (≥20 mm) laterally spreading tumors (LSTs) or nonpedunculated colorectal polyps; however, there is a lack of clear consensus on the management of these lesions with significant geographic variability especially between Eastern and Western paradigms. We aimed to provide an international consensus to better guide management and attempt to homogenize practices. METHODS: Two experts in interventional endoscopy spearheaded an evidence-based Delphi study on behalf of the World Endoscopy Organization Colorectal Cancer Screening Committee. A steering committee comprising six members devised 51 statements, and 43 experts from 18 countries on six continents participated in a three-round voting process. The Grading of Recommendations, Assessment, Development and Evaluations tool was used to assess evidence quality and recommendation strength. Consensus was defined as ≥80% agreement (strongly agree or agree) on a 5-point Likert scale. RESULTS: Forty-two statements reached consensus after three rounds of voting. Recommendations included: three statements on training and competency; 10 statements on preresection evaluation, including optical diagnosis, classification, and staging of LSTs; 14 statements on endoscopic resection indications and technique, including statements on en bloc and piecemeal resection decision-making; seven statements on postresection evaluation; and eight statements on postresection care. CONCLUSIONS: An international expert consensus based on the current available evidence has been developed to guide the evaluation, resection, and follow-up of LSTs. This may provide guiding principles for the global management of these lesions and standardize current practices.

Gastrointestinal Foreign Bodies: 14 Years of Experience in a University Clinic

Introduction: Ingesting foreign bodies is a common medical problem, especially in the emergency department. Some small studies describe experiences in this regard. Materials and methods: A descriptive retrospective study included patients with suspected ingestion of foreign bodies admitted to the gastroenterology and GI endoscopy service of the Clínica Universitaria Colombia between January 2007 and August 2020. Results: The age of occurrence of the event was 18 to 95 years, and the average age was 45 years. The foreign bodies ingested and found were variable. The most frequent was fish bones, representing 64.11% of the cases, followed by chicken bones and dietary impaction. Thirty-eight percent of patients required foreign body removal; the most frequently used tool was the foreign body forceps. The primary location was the esophagus in 12.53% of cases, followed by the cricopharynx in 11.18% and the hypopharynx in 10%. Conclusions: The Clínica Universitaria Colombia is a referral site for many gastroenterology emergencies due to its high technological level and extensive human resources. This paper probably describes the largest number of patients with this reason for consultation, which is why this retrospective descriptive study was designed. It shows the demographic characteristics, foreign body types, radiological and endoscopic findings, and associated complications, which help to provide a more accurate knowledge of this pathology.

Introducción: La ingesta de cuerpos extraños es un problema médico frecuente, especialmente en el servicio de urgencias. Existen algunos estudios pequeños que describen las experiencias al respecto. Materiales y métodos: Estudio descriptivo, retrospectivo, en el cual se incluyó a pacientes con sospecha de ingesta de cuerpos extraños, ingresados al servicio de gastroenterología y endoscopia digestiva de La Clínica Universitaria Colombia, entre enero de 2007 y agosto de 2020. Resultados: La edad de ocurrencia del evento se presentó en pacientes desde los 18 hasta los 95 años, y la edad promedio fue de 45 años. Los cuerpos extraños ingeridos y encontrados fueron variables; los más frecuentes fueron la ingesta de espinas de pescado, que representó el 64,11% de los casos, seguido por la ingesta de huesos de pollo y la impactación alimentaria. Un 38% de los pacientes requirieron la extracción de cuerpo extraño y la herramienta usada con mayor frecuencia fue la pinza de cuerpo extraño. La localización principal fue el esófago, en el 12,53% de los casos, seguido por la cricofaringe, en el 11,18%, y la hipofaringe, en el 10%. Conclusiones: La Clínica Universitaria Colombia es un sitio de referencia de una gran cantidad de urgencias en gastroenterología debido a su alto nivel tecnológico y al gran recurso humano que requieren. Este trabajo representa probablemente la cantidad más grande de pacientes con este motivo de consulta, razón por la que se diseñó este estudio descriptivo retrospectivo, que muestra las características demográficas, los tipos de cuerpo extraño, los hallazgos radiológicos y endoscópicos y las complicaciones asociadas, que son de utilidad para tener un conocimiento más real de esta patología.

Inteligencia artificial en la colonoscopia de tamizaje y la disminución del error.

Artificial Intelligence (AI) has the potential to change many aspects of healthcare practice. Image discrimination and classification has many applications within medicine. Machine learning algorithms and complicated neural networks have been developed to train a computer to differentiate between normal and abnormal areas. Machine learning is a form of AI that allows the platform to improve without being programmed. Computer Assisted Diagnosis (CAD) is based on latency, which is the time between the captured image and when it is displayed on the screen. AI-assisted endoscopy can increase the detection rate by identifying missed lesions. An AI CAD system must be responsive, specific, with easy-to-use interfaces, and provide fast results without substantially prolonging procedures. AI has the potential to help both, trained and trainee endoscopists. Rather than being a substitute for high-quality technique, it should serve as a complement to good practice. AI has been evaluated in three clinical scenarios in colonic neoplasms: the detection of polyps, their characterization (adenomatous vs. non-adenomatous) and the prediction of invasive cancer within a polypoid lesion.

La inteligencia artificial (IA) tiene el potencial de cambiar muchos aspectos de la práctica sanitaria. La discriminación y la clasificación de imágenes tiene muchas aplicaciones dentro de la medicina. Se han desarrollado algoritmos de aprendizaje automático y redes neuronales complicadas para entrenar a una computadora a diferenciar las áreas normales de las anormales. El aprendizaje automático es una forma de IA que permite que la plataforma mejore sin ser programada. El diagnóstico asistido por computadora (CAD) se basa en latencia, que es el tiempo entre la imagen capturada y cuando es mostrada en la pantalla. La endoscopia asistida por IA puede incrementar la tasa de detección al identificar lesiones obviadas. Un sistema CAD de IA debe ser sensible, específico, con interfaces fáciles de usar, y proporcionar resultados rápidos sin prolongar sustancialmente los procedimientos. La IA tiene el potencial de ayudar tanto a endoscopistas entrenados como a los que están en entrenamiento. En vez de ser un sustituto para una técnica de alta calidad, deberá servir como un complemento de las buenas prácticas. La IA ha sido evaluada en tres escenarios clínicos en las neoplasias colónicas: la detección de pólipos, su caracterización (adenomatosos vs. no adenomatosos) y la predicción de cáncer invasor dentro de una lesión polipoide.

Wide-field ESD for Barrett's adenocarcinoma at the gastroesophageal junction: technical approaches to facilitate en bloc R0 resection.

Video 1Wide-field ESD for Barrett's adenocarcinoma.

Usefulness of optical enhancement endoscopy combined with magnification to improve detection of intestinal metaplasia in the stomach.

Background and study aims The light blue crest observed in narrow band imaging endoscopy has high diagnostic accuracy for diagnosis of gastric intestinal metaplasia (GIM). The objective of this prospective study was to evaluate the diagnostic accuracy of magnifying i-scan optical enhancement (OE) imaging for diagnosing the LBC sign in patients with different levels of risk for gastric cancer in a Mexican clinical practice. Patients and methods Patients with a history of peptic ulcer and symptoms of dyspepsia or gastroesophageal reflux disease were enrolled. Diagnosis of GIM was made at the predetermined anatomical location and white light endoscopy and i-scan OE Mode 1 were captured at the two predetermined biopsy sites (antrum and pyloric regions). Results A total of 328 patients were enrolled in this study. Overall GIM prevalence was 33.8 %. The GIM distribution was 95.4 % in the antrum and 40.5 % in the corpus. According to the Operative Link on Gastritis/Intestinal-Metaplasia Assessment staging system, only two patients (1.9 %) were classified with high-risk stage disease. Sensitivity, specificity, positive​ and negative predictive values, positive and negative likelihood ratios, and accuracy of both methods (95 % C. I.) were 0.50 (0.41-0.60), 0.55 (0.48-0.62), 0.36 (0.31-0.42), 0.68 (0.63-0.73), 1.12 (0.9-1.4), 0.9 (0.7-1.1), and 0.53 (0.43-0.60) for WLE, and 0.96 (0.90-0.99), 0.91 (0.86-0.94), 0.84 (0.78-0.89), 0.98 (0.94-0.99), 10.4 (6.8-16), 0.05 (0.02-0.12), and 0.93 (0.89-0.95), respectively. The kappa concordance was 0.67 and the reliability coefficient was 0.7407 for interobserver variability. Conclusions Our study demonstrated the high performance of magnifying i-scan OE imaging for endoscopic diagnosis of GIM in Mexican patients.

Rio de Janeiro Global Consensus on Landmarks, Definitions, and Classifications in Barrett's Esophagus: World Endoscopy Organization Delphi Study.

BACKGROUND & AIMS: Despite the significant advances made in the diagnosis and treatment of Barrett's esophagus (BE), there is still a need for standardized definitions, appropriate recognition of endoscopic landmarks, and consistent use of classification systems. Current controversies in basic definitions of BE and the relative lack of anatomic knowledge are significant barriers to uniform documentation. We aimed to provide consensus-driven recommendations for uniform reporting and global application. METHODS: The World Endoscopy Organization Barrett's Esophagus Committee appointed leaders to develop an evidence-based Delphi study. A working group of 6 members identified and formulated 23 statements, and 30 internationally recognized experts from 18 countries participated in 3 rounds of voting. We defined consensus as agreement by ≥80% of experts for each statement and used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool to assess the quality of evidence and the strength of recommendations. RESULTS: After 3 rounds of voting, experts achieved consensus on 6 endoscopic landmarks (palisade vessels, gastroesophageal junction, squamocolumnar junction, lesion location, extraluminal compressions, and quadrant orientation), 13 definitions (BE, hiatus hernia, squamous islands, columnar islands, Barrett's endoscopic therapy, endoscopic resection, endoscopic ablation, systematic inspection, complete eradication of intestinal metaplasia, complete eradication of dysplasia, residual disease, recurrent disease, and failure of endoscopic therapy), and 4 classification systems (Prague, Los Angeles, Paris, and Barrett's International NBI Group). In round 1, 18 statements (78%) reached consensus, with 12 (67%) receiving strong agreement from more than half of the experts. In round 2, 4 of the remaining statements (80%) reached consensus, with 1 statement receiving strong agreement from 50% of the experts. In the third round, a consensus was reached on the remaining statement. CONCLUSIONS: We developed evidence-based, consensus-driven statements on endoscopic landmarks, definitions, and classifications of BE. These recommendations may facilitate global uniform reporting in BE.

Trends and predictors of 30-day readmissions in subjects with eosinophilic esophagitis: results from a national cohort.

BACKGROUND: Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory condition causing recurrent dysphagia and may predispose patients to repeated hospitalizations. We assessed temporal trends and factors affecting readmissions in patients with EoE. METHODS: Patients with primary diagnosis of EoE and/or a complication (dysphagia, weight loss, and esophageal perforation) from EoE between 2010 and 2017 were identified from the National Readmissions Database using the International Classification of Diseases codes. The primary outcome was incidence of EoE related 30-day readmission. Independent risk factors for readmissions were evaluated using multivariable logistic regression analysis. Secondary outcomes were temporal trends of readmissions and healthcare costs. RESULTS: Of the 2,676 (mean age 45 ± 17.8 years, 1,667 males) index adult admissions, 2,103 (79%) patients underwent an upper endoscopy during the admission. The mean length of stay (LOS) was 3 ± 3.7 days. The 30-day readmission rate was steady at 6.8% from 2010 to 2017 and majority of the readmissions occurred by day 10 of index discharge. Age > 70 years was associated with a higher trend in 30-day readmission (P < 0.001). Longer LOS, history of smoking and the presence of eosinophilic gastroenteritis predicted readmission. Conversely, a history of foreign body impaction and upper endoscopy (including esophageal dilation) at index admission were negatively associated with readmission. Mean hospital charges significantly increased from $24,783 in 2010 to $40,922 in 2017. CONCLUSION: Readmissions due to EoE are more likely to occur in the first 10 days of discharge and at a lesser rate when upper endoscopies are performed at the index admission.

Novel approaches to minimize intraoperative bleeding during endoscopic submucosal dissection of a large rectal lateral spreading tumor extended to the dentate line with internal hemorrhoids.

Video 1Endoscopic submucosal dissection (ESD) of large rectal lateral spreading tumors (LSTs) that extend to the dentate line with internal hemorrhoids is a challenging procedure because of the increased risk of bleeding from penetrating and hemorrhoidal vessels and the reduced visual field caused by the dilated venous packages and the narrow anal lumen.This video describes novel technical approaches to minimize the risk of intraoperative bleeding.The described approaches are indicated in large rectal LSTs that extend to the dentate line with large internal hemorrhoids. The described selective-vessel approach is also indicated in any vascularized superficial lesion amenable to endoscopic treatment.ESD was performed in the retroflex view using an Evis Exera II video processor, an H180 gastroscope, an ERBE ICC 200, and CO2 insufflation. As tools, IT-nano, needle knife, hook knife, hemostatic forceps, and a distal cap were used. The lifting solution was a mixture of normal saline, hyaluronic acid, epinephrine, and indigo carmine.A hemicircumferential superficial granular lateral spreading tumor was observed in the lower rectum. Indigo carmine dye spray facilitated the identification of the lesion's margin and demonstrated no ulcer, converging folds, or large nodules. After the submucosal (SM) injection, a shallow mucosal incision was made in the retroflex view using a conventional needle knife, followed by the circumferential incision at the proximal side using an IT-nano. The SM layer was dissected at a superficial level to avoid large SM vessels, thus preventing intraoperative bleeding and maintaining a clean surgical field. Small vessels were selectively coagulated mainly by using the small disc located at the back of the insulated tip as the SM later was superficially dissected. To facilitate precise coagulation, a stepwise dissection technique was used for larger vessels. After identification, the vessel was first exposed by dissecting the surrounding SM layer at the left and right sides using the long blade of IT-nano, with blunt dissection of the surrounding tissue at the vessels' posterior aspect using a Hook knife. Double-vessel sealing using a hemostatic forceps was performed both at the rectal and tumor sides. Lastly, the vessel was transected between sealed segments using the IT-nano, without major bleeding. The circumferential incision was completed at the left side and distally extended to the anal canal where large hemorrhoidal bundles were seen. A needle knife was used to complete the SM dissection and, here, the final cut. En bloc resection was successfully achieved without intraoperative bleeding.The en bloc resected specimen was 85 mm in size, and squamous epithelium of the anal canal was observed at the distal margin. Colonoscopy 5 months post-ESD revealed adequate healing, no stenosis and no hemorrhoids.Coagulation and hemostasia should be promptly carried out whenever inadvertent injury to large vessels and subsequent bleeding occurs during lateral exposure, posterior blunt dissection, double coagulation, and transection of vessels.Curative ESD can be achieved in large rectal LSTs that extend to the dentate line with large internal hemorrhoids. Strategies to minimize intraoperative bleeding during ESD should be considered and include the following:•An SM dissection from the proximal tumor margin in the retroflex view to circumvent contact with hemorrhoids.•A differential level of dissection to prevent inadvertent vessel injury-shallow first to avoid large SM vessels and deeper above the muscular layer closer to the dentate line to shut off blood supply by penetrating hemorrhoidal vessels.•Last but not least, a selective approach to vessels to reduce the risk of bleeding, with direct coagulation for small vessels and with lateral exposure, posterior blunt dissection, double-vessel sealing, and transection between sealed segments for larger vessels.

What gastroenterologists should know about SARS-CoV 2 vaccine: World Endoscopy Organization perspective.

BACKGROUND: The novel Coronavirus (SARS-CoV-2) has caused almost 2 million deaths worldwide. Both Food and Drug Administration and European Medicines Agency have recently approved the first COVID-19 vaccines, and a few more are going to be approved soon. METHODS: Several different approaches have been used to stimulate the immune system in mounting a humoral response. As more traditional approaches are under investigation (inactivated virus vaccines, protein subunit vaccines, recombinant virus vaccines), more recent and innovative strategies have been tried (non-replicating viral vector vaccines, RNA based vaccines, DNA based vaccines). RESULTS: Since vaccinations campaigns started in December 2020 in both the US and Europe, gastroenterologists will be one of the main sources of information regarding SARS-CoV 2 vaccination for patients in their practice, including vulnerable patients such as those with Inflammatory Bowel Disease (IBD), patients with chronic liver disease, and GI cancer patients. CONCLUSIONS: Thus, we must ourselves be well educated and updated in order to provide unambiguous counseling to these categories of vulnerable patients. In this commentary, we aim to provide a comprehensive review of both approved COVID-19 vaccines and the ones still under development, and explore potential risks, benefits and prioritization of vaccination.

COVID-19 and endoscopic management of superficial gastrointestinal neoplastic lesions: a multinational cross-sectional survey.

INTRODUCTION: We aimed to report the impact of the pandemic lockdown period on the treatment and prognosis of superficial gastrointestinal neoplastic lesions. METHODS: A survey was completed by 11 centers from four continents regarding postponements during the early lockdown period of the pandemic, and the same period in 2019. RESULTS: In 2020, 55 % of the scheduled procedures were deferred, which was 11 times higher than in 2019; the main reasons were directly related to COVID-19. In countries that were highly affected, this proportion rose to 76 % vs. 26 % in those where there was less impact. Despite the absolute reduction, the relative distribution in 2019 vs. 2020 was similar, the only exception being duodenal lesions (affected by a 92 % reduction in mucosectomies). Although it is expected that the majority of postponements will not affect the stage (based on the results from biopsies and/or endoscopic appearance), 3 % of delayed procedures will probably require surgery. CONCLUSIONS: The lockdown period caused by the SARS-CoV-2 pandemic led to a substantial reduction in the number of endoscopic resections for neoplastic lesions. Nevertheless, based on clinical judgment, the planned median delay will not worsen the prognosis of the affected patients.

Recovery of endoscopy services in the era of COVID-19: recommendations from an international Delphi consensus.

The COVID-19 pandemic has had a profound impact on provision of endoscopy services globally as staff and real estate were repurposed. As we begin to recover from the pandemic, a cohesive international approach is needed, and guidance on how to resume endoscopy services safely to avoid unintended harm from diagnostic delays. The aim of these guidelines is to provide consensus recommendations that clinicians can use to facilitate the swift and safe resumption of endoscopy services. An evidence-based literature review was carried out on the various strategies used globally to manage endoscopy during the COVID-19 pandemic and control infection. A modified Delphi process involving international endoscopy experts was used to agree on the consensus statements. A threshold of 80% agreement was used to establish consensus for each statement. 27 of 30 statements achieved consensus after two rounds of voting by 34 experts. The statements were categorised as pre-endoscopy, during endoscopy and postendoscopy addressing relevant areas of practice, such as screening, personal protective equipment, appropriate environments for endoscopy and infection control precautions, particularly in areas of high disease prevalence. Recommendations for testing of patients and for healthcare workers, appropriate locations of donning and doffing areas and social distancing measures before endoscopy are unique and not dealt with by any other guidelines. This international consensus using a modified Delphi method to produce a series of best practice recommendations to aid the safe resumption of endoscopy services globally in the era of COVID-19.

Recommendations for the Operation of Endoscopy Centers in the setting of the COVID-19 pandemic - World Endoscopy Organization guidance document.

Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) is the etiologic agent causing the disease Corona Virus Disease 19 (COVID-19), resulting in a worldwide pandemic. Non-emergent endoscopy services have been disrupted as incidence and hospitalizations were rising. It is anticipated that the peak incidence may be leveling off in many parts of the world, but there is a concern for resurgence of the virus activity. Thus, it is important for endoscopy units to have plans in place during peak times of the epidemic and when resuming endoscopic services as the pandemic wanes. The global endoscopy community is faced with the challenge of providing care during this time. The WEO-COVID guidance task force has provided this resource document based on the current evidence and consensus opinion. These World Endoscopy Organization (WEO) recommendations are meant to guide endoscopists worldwide, should be interpreted in light of specific clinical conditions and resource availability and may not apply in all situations. This guidance document does not supersede the need to check for all local regulations and legislations.

Practical advice for management of inflammatory bowel diseases patients during the COVID-19 pandemic: World Endoscopy Organization Statement.

COVID-19 is rapidly spreading worldwide and specific literature how to deal with inflammatory bowel diseases (IBD) patients is limited so far. Here, the World Endoscopy Organisation is providing practical advice for the management of IBD patients during the pandemic covering the diagnostic and therapeutic spectrum.

Principles and practice to facilitate complete photodocumentation of the upper gastrointestinal tract: World Endoscopy Organization position statement.

Although esophagogastroduodenoscopy (EGD) is the most commonly used procedure in the gastrointestinal (GI) tract, the method of esophageal, gastric and duodenal mucosa photodocumentation varies considerably worldwide. One probable explanation is that for generations, EGD has primarily been taught by GI faculty and instructors based on their perceptions and experience, which has resulted in EGD being a non-standardized procedure. Currently, the procedure is facing a challenging scenario as endoscopy societies are implementing procedure-associated quality indicators aiming for best practice among practitioners and evidence-based care for patients. Contrary to colonoscopy where cecum landmarks photodocumentation is considered proof of completeness, there are currently no reliable performance measures to gauge the completeness of an upper endoscopy nor guidance for complete photodocumentation. This World Endoscopy Organization (WEO) position statement aims to provide practical guidance to practitioners to carry out complete EGD photodocumentation. Hence, an international group of experts from the WEO Upper GI Cancer Committee formulated the following document using the body of evidence established through literature reviews, expert opinions, and other scientific sources. The group acknowledged that although the procedure should be feasible in any facility, what is needed to achieve a global shift on the concept of completeness is a common written statement of agreement on its potential impact and added value. This best practice statement offers endoscopists principles and practical guidance in order to carry out complete photodocumentation from the hypopharynx to the second duodenal portion.